The Importance of Psychological Support for the Implantable Cardioverter Defibrillator Patient

Thu, 5/1/08 - 3:22pm
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Author(s):

Patricia A. Metoyer, MS, RN, APN-C, Nurse Practitioner

Heller et al. indicated that for some patients, the shock is not preceded by symptoms of any kind and is without warning; others develop symptoms of tachyarrhythmia and often await the shock with trepidation. The situation creates an experience of ambivalence: without the device, the patient may die, but with the device, there is constant anticipation that the device will fire. The fear and anticipation of shock can lead to psychological and emotional problems that are unique to this population. Many in the psychological community^4-6 and those in the cardiology community^7-10 have supported the notion that psychological support is needed to assist these patients with the adjustments needed to maintain an active lifestyle. Giving these patients psychological support, through education and supportive follow-up, may help those with an ICD reduce the incidence of fear, isolation and other negative responses.

The effectiveness of the implantable cardioverter defibrillator (ICD) in preventing sudden cardiac death is based on its proven capacity to convert 98% of ventricular tachycardias to normal sinus rhythm.¹¹ Since the introduction of the ICD in 1980, there has been a striking reduction in mortality in patients with documented sustained ventricular tachycardia, as well as those with inducible ventricular arrhythmias.¹² New technological advances offer sophisticated arrhythmia detection and programmable treatments.¹³ Recently, cardiac resynchronization therapy (CRT) was introduced and added to the programming capabilities of the ICD. CRT involves placing a lead in the coronary sinus as well as the right atrium and ventricle to optimize the order of contraction and enhance physiologic functioning of the cardiac circuit. The result is reduced mitral regurgitation, increased diastolic filling time, and improved contractility of the cardiac muscle.¹¹ Given the results of past clinical trials such as AVID, MUSTT, and MADIT I, as well as more recent trials such as MADIT II, COMPANION and SCD-HeFT, it is expected that many more implants will take place for high-risk sudden cardiac death (SCD) and heart failure patients.^2,11

The majority of patients who are implanted with the device experience a desirable quality-of-life and a high acceptance rate. Thirty to fifty percent of patients reported some degree of negative effect, such as fear, anxiety, and depression.¹⁴ Additionally, lifestyle changes that affect driving, sexual activity, social interactions, physical appearance and physical activity further complicate the life of the recipient. Younger implanted patients, some as young as 4 years of age, those < 50 years of age, and those who experience high rates of shocks have been identified as being at special risk for development of psychological distress and poor health outcomes.^14,15

References:

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2. Prudente LA. Psychological disturbances, adjustment, and the development of phantom shocks in patients with an implantable cardioverter defibrillator. J Cardiovascular Nursing 2005;20:288-293.

3. Heller SS, Ormont MA, Lidagoster L, et al. Psychosocial outcome after ICD implantation: A current perspective. PACE 1998;21:1207-1215.

4. Sears SF Jr., Conti JB, Curtis AB, et al. Affective distress and implantable cardioverter defibrillators: Cases for psychological and behavioral interventions. PACE 1999;22:1831-1834.

5. Pauli P, Wiedemann G, Dengler W, et al. Anxiety in patients with an automatic implantable defibrillator: What differentiates them from panic patients? Psychosomatic Medicine 1999;61:69-76.

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.20. Smith LC, Fogel D, Friedman S. Cognitive-behavior treatment of panic disorder with agoraphobia triggered by AICD implant activity. Psychosomatics 1998;39:475-477.

21. Fitchet A, Doherty PJ, Bundy C, et al. Comprehensive cardiac rehabilitation programme for implantable cardioverter defibrillator patients: A randomized controlled trial. Heart 2005;89:155-160.

22. Pauli P, Wiedemann G, Dengler W, Kuhlkamp V. A priori expectancy bias and its relation to shock experience and anxiety: A naturalistic study in patients with an automatic implantable cardioverter defibrillator. J Behavior Therapy 2001;32:159-171.